Happiness can wait

Since 6-year-old Jazz Jennings appeared in a 2007 US documentary, the social transition of young transgender children has rarely been out of the media. With increasing awareness accompanied by increasing evidence of the mental health benefits of acceptance and affirmation, more parents across the world are supporting their transgender child to socially transition.

For children of any age, gender transition means allowing the child to choose how they express their gender. Children may:

Wear clothing that affirms their gender, such as skirts for transgender girls

Adopt a hairstyle that affirms their gender, such as a short haircut for transgender boys

Choose a name that affirms their gender

Ask others to call them by pronouns (such as “he” or “she” or “they”) that affirm their gender

Use bathrooms and other facilities that match their gender identity”

Social transition is completely reversible if the child determines it’s not right for them.”

Some ‘experts’ in Europe, in opposition to experts in North America and Australia, caution against social transition. A example of a European ‘expert’ cautioning against social transition is a 2017 Swedish publication on transgender children by Louise Frisen et al:

The Frisen article has some positive sections, but it does also include some outdated statements that I am weary of reading in journal articles:

“Follow-up studies show that no more than about 20 percent of pre-puberty children who meet diagnosis criteria for sex dysphoria will have a residual desire for gender confirmation [6-8].”

And I was shocked to see this recommendation:

“Restraint for the younger with early social transition

Since no more than about 20 percent of prepubertal children who meet gender diagnosis criteria will have a residual desire for gender confirmation [6-8], the recommendation for the younger children is restraint regarding early social transition (living as the perceived gender). It is important to discuss the social consequences and to be aware that the majority of the younger children will not have a remaining desire for gender confirmation.”

The recommendation against social transition, and the two statements quoted above rely on just three sources:

The above reference 6 (Drummond) and reference 8 (Wallien) are two discredited studies on desistance that have been widely criticised see here

Reference 7 (Steensma) is a study with totally unreliable conclusions, as discussed here:

The Swedish paper contains no acknowledgement that the data it quotes on the number of transgender children continuing to be transgender as adults are highly contested and could be completely wrong as discussed here

I am so tired of seeing these same unreliable (unscientific, unethical, unsound, shambolic) studies trotted out time and again in journal articles.

Parents of transgender children do not normally have the time, the access to the referenced literature (in inaccessible / expensive academic journals) or the capacity to fact check the advice they are given. And they should not have to. This is literally the job of the supposed experts writing papers like this latest Swedish one. The reliance on discredited studies and conclusions is deeply worrying.

And the advice against social transition can cause serious harm.

he Swedish study advising against social transition is worrying, not only due to the inclusion of unreliable/discredited research in their paper as discussed above, but also due to the exclusion of critical information that Swedish parents (and those caring for Swedish transgender children) have a right to know such as research demonstrating the benefits of social transition, and the positions of world leading experts from the American Academy of Pediatrics and ANZPATH, both of whom endorse social transition.

The Swedish paper does not mention the latest research study from Olson in the United States showing that socially transitioned and supported children have higher levels of mental well being than children who are living as their natal sex:

“Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.”

“In many cases, the remedy for dysphoria is gender transition: taking steps to affirm the gender that feels comfortable and authentic to the child. It is important to understand that, for children who have not reached puberty, gender transition involves no medical interventions at all: it consists of social changes like name, pronoun and gender expression.

While acceptance and affirmation at home can help a great deal, children do not grow up in a vacuum, so even children with supportive families may experience dysphoria. Nonetheless, families and doctors of transgender children often report that the gender transition process is transformative — even life-saving. Often, parents and clinicians describe remarkable improvements in the child’s psychological well-being.

The American Academy of Pediatrics describes social transition as “transformative – even life saving”. They continue:

A child’s gender transition is almost always a positive event. Often, the child’s debilitating gender dysphoria symptoms lift, diminishing difficult behavior that came with them. Dr. Ehrensaft calls this the ex post facto (“after the fact”) test: a dramatic reduction in stress, and blossoming happiness for the child and family, indicate that social transition has been the right choice. Along with joy at this renewed well-being, families are often thrilled to find that gender transition removes the emphasis on gender in a child’s life. With their gender identity no longer in conflict, the child can focus on the important work of learning and growing alongside their peers. Many children feel relief, even euphoria, that the adults in their life have listened and understood them.

This describes exactly our experience. Over night our daughter went from incredibly sad and distressed to a happy, carefree child. She went from wanting to talk about gender every single night to completely losing interest in the topic once the world was set to rights as we had accepted her as a girl.

The American Academy of Pediatrics are also very clear why those who, like the Swedish experts, advocate for delayed transition for all children, are wrong:

Delayed Transition: Prolonging Dysphoria

“delayed transition prohibits gender transition until a child reaches adolescence or even older, regardless of their gender dysphoria symptoms.

There is evidence that both reparative therapy and delayed transition can have serious negative consequences for children”

Many children who are gender-expansive or have mild gender dysphoria do not grow up to be transgender — but these are not the children for whom competent clinicians recommend gender transition.”

Delayed-transition advocates treat unnecessary or mistaken gender transition as the worst-case scenario, rather than balancing this risk with the consequences of the delay.

Untreated gender dysphoria can drive depression, anxiety, social problems, school failure, self-harm and even suicide.

There is no evidence that another transition later on, either back to the original gender or to another gender altogether, would be harmful for a socially transitioned child — especially if the child had support in continuing to explore their gender identity.

While delaying a child’s gender exploration can cause serious harm, a deliberate approach is wise. Some children need more time to figure out their gender identity, and some do best by trying out changes more slowly. For these children, rushing into transition could be as harmful as putting it off. The problem with “delayed transition” is that it limits transition based on a child’s age rather than considering important signs of readiness, particularly the child’s wishes and experiences. A gender-affirmative approach uses this broader range of factors, with particular attention to avoiding stigma and shame.”

For children with mild gender dysphoria, the family and therapist’s affirmation of their gender expansive traits often relieves their distress. For this group, it appears that gender dysphoria — and even a moderate desire to change gender — can result from trouble reconciling their masculinity or femininity with being a girl or boy. Adolescents affirmed in their gender-expansive traits are happier and healthier, whether or not they grow up to identify as transgender.

Other children have an insistent, consistent and persistent transgender identity; they thrive only when living fully in a different gender than the one matching the sex assigned at birth. In differentiating these children from the gender-expansive children described above, clinicians use two general rules: They focus on a child’s statements about their sex and gender identity, not their gender expression (masculinity or femininity), and they look for “insistent, consistent and persistent” assertions about that identity. Clinicians help these children and their families socially affirm the child’s gender identity.

The latest ANZPATH (Australian Professional Association for Transgender Health) provides similar clear, evidence based guidance for those supporting transgender children:

“Increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and well being outcomes can be significantly improved.

Social transition should be led by the child and does not have to take an all or nothing approach.

Social transition can reduce a child’s distress and improve their emotional functioning. Evidence suggest that trans children who have socially transitioned demonstrate levels of depression, anxiety and self-worth comparable to their cisgender peers.

The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

Acceptance = love. Rejection = shame

Remember, social transition is a fully reversible change involving a change of pronoun, perhaps accompanied by a change of hair style, clothing, name. Nothing medical at all.

At its heart, a social transition is a clear message to a child that they are OK, that they are accepted, that they are not wrong or broken, that they are loved.

The Swedish study takes the view that there is a paucity of evidence, therefore children should not be supported to socially transition.

I agree that there is a paucity of rigorous long-term scientific studies on the outcomes for children who from an early age are supported and accepted.

What does exist is a whole heap of anecdotal evidence of the huge benefit of social transition. I personally know of over a hundred families for whom social transition has been transformational for their child’s happiness. Experts in Australia and America have found the same.

I have met scores of families whose only regret is that they did not embrace and support their child earlier. This includes our child. She was miserable every day – in acute distress. Since social transition she is one of the happiest children you can find. Loving school. Loving her friends. Having a wonderful childhood. Time and again from parents all over the world I hear the exact same story. A story that I hadn’t even heard before I lived it with my child.

From these very many happy socially transitioned children, I know of 2 cases where after a few years of social transition, the child has said to their parent, I want to try living as my assigned gender. In these small number of cases, a second social transition occurred that was no more difficult than the first social transition. At all stages a child needs to feel loved and accepted, that their family are listening to and respecting them. I know of a few more children who have grown into embracing a more nuanced or complex non-binary identity as they have got older (perhaps as they grow more aware of the existence of space between two binaries). Again – no known harm to those children whose understanding of their identity expands over time – as long as they are loved, cared for and accepted.

What is very well evidenced is the great harm that is caused when children are rejected, forced to live a lie, told that who they are is wrong or disturbed or shameful or unacceptable. The message trans girls learn quickly when their parents refuse to call them a girl.

Parents of transgender children know all too well that there is not enough useful research out there. We know that we have been deeply let down by past decades of research on transgender children that is not useful. Let down through the transphobia, homophobia, cis-het-normativity and or sheer incompetence of past researchers who failed to distinguish between trans and gender non-conforming children, and failed to explore which options would lead to the best outcomes for transgender children – including of course the option to affirm, love and accept them.

Much transphobic research continues in this vein. A few researchers, like Kristina Olson from the Trans Youth Project at the University of Washington, are now tracking the outcomes of socially transitioned, affirmed, supported children.

“withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal”

The suggestion that ‘do nothing’ is even an option for parents of insistent, consistent, persistent transgender children is a mis-characterisation of life with a distressed child. As I describe in an earlier blog post

People say: “The best course of action would be for parents not to make any decisions at all”

This shows little understanding of what it is like to parent a transgender child.

Life is full of decisions.

Before making the extremely difficult and heart-breaking decision to support my child, for months I made the decision to say ‘I love you, but no, you are not a girl you are a boy’ and watched their sad face.

For months later, when they said ‘I am a girl’ I decided to change the subject or look away.

For months further I avoided directly calling them a boy but decided to sit in silence as others called them a boy and I watched their shoulders hunch in and the sad look of rejection on their face.

For months further I sat with them at bedtime as they cried and listened to them say ‘but I am a girl’ and I decided not to say ‘that is OK, we love you whatever’.

Life with a very insistent transgender child is full of difficult and painful and troubling decisions for a parent who cares deeply for their child.

Making a decision finally to say ‘that’s OK, we love you whatever’ was the latest in a very long line of decisions.

Which eventually moved on to ‘OK, we’ll call you a girl’, and ‘OK, we’ll help others to call you a girl’ and ‘OK, we’ll help others to understand you are a girl’.

We do not wake up one morning and think, wouldn’t it be fun to choose this incredibly hard and traumatic path for our children.

The above are my words from a couple of years ago. My perspective and understanding has shifted a great deal over the past few years and I no longer see being transgender as a negative or scary thing (though I dearly wish my child would not have to face a transphobic world or deal with prejudice and hate). But at the time I was ignorant and very afraid.

Parents do not consider supporting their child to socially transition on a whim. Take a look at the first 5 mins of this video in this link and see the experience of one American family.

Parents working up the courage to support their transgender child already have to overcome their own transphobia and ignorance (the vast majority of the cis parents I know knew nothing at all about trans children before our own child).

Parents working up the courage to support their transgender child already face extreme hostility from wider society. We already face social isolation and losing friends and family. It is not easy, even when a parent knows in their heart it is what their child needs.

Parents in this situation need ‘experts’ who understand what is at stake, who present all the facts and all recent research including the evidence in favour of social transition. We need experts who are willing to offer support and guidance to families and children for whom extended delay, extended rejection, extended denial of identity is cruelty to our transgender child.

To force children to live as their assigned gender, when doing so is causing them deep distress; to tell them to ‘wait until we have long term data’, when we know anecdotally how many children benefit from social transition, when we know zero evidence of harm, is gross negligence.

The ‘experts’ telling families to ‘wait until we have long term data on the outcomes for those socially transitioned children who we know are currently happy and thriving’ are telling parents to keep their child in a state of deep distress for no good reason. These ‘experts’ like this Swedish author have presumably not spent night after night holding a deeply distressed miserable child. They presumably have not watched their child shrink and lose all enjoyment of life. They also can’t have spent much time around children like mine who absolutely shine with happiness now that they have socially transitioned.

On one level, supporting a child to socially transition seems like the biggest, scariest, most inconceivable step in the world. And, at the time, for a family surrounded by a sceptical and transphobic community, it is.

But, on another level, it is just a change of pronoun. It is the smallest change in the world, and the biggest bargain out there. For this small change I got my happy child back. For this small change my child found love and acceptance instead of rejection and shame. For this small change my child got a carefree childhood full of games and play and friends and fun.